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Aquatic Nuisance Control General Permit Notice of Intent – Aquatic Nuisance Control Activity Under Chapter 50 of Title 10, § 1455

Application Number:

For Lake & Shoreland Permitting Use Only

Submission of this completed Notice of Intent (NOI) constitutes notice that the applicant identified in Section A intends to be authorized to conduct a nonchemical aquatic nuisance control activity in the waters identified in Section C that targets only aquatic plants using benthic barriers, diver assisted suction harvesting, or a combination of the two, under the Aquatic Nuisance Control General Permit (ANCGP). To be granted coverage, all information required on this form must be completed and the requisite fees (Section G) must be submitted made payable by check to the State of Vermont. This permit and is subject to a 14-day public comment period posted to the Environmental Notice Bulletin (https://enb.vermont.gov).

A. Applicant Information

1. Applicant’s Name:

2a. Mailing Address:

2b. Municipality: 2c. State: 2d. Zip:

3.Phone: 4. Email:

5. Check the box to the right to identify whether the applicant is aregistered lake association or an individual shoreline property owner:

If the applicant is a registered lake association, provide a copy of its approved registration form, or if not previously registered, a new registration form as an attachment to this NOI.

Note: Only complete questions A.6a-e. below if the applicant is an individual shoreline property owner.

Registered Lake Association

Individual Shoreline Property Owner

6a. Shoreline Property Physical Address (911 Address):

6b. Town - County: 6c. Zip:

6d. SPAN (###-###-#####):

(The School Parcel Account Number, SPAN, can be obtained from your property tax bill or requested from your Town Clerk)

6e. Coordinates (Decimal degrees, can be found on Google Maps): ,

B. Application Preparer Information (check the box to the right if same as Section A above )

1. Preparer’s Name:

2a. Mailing Address:

2b. Municipality: 2c. State: 2d. Zip:

3. Phone: 4. Email:

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1a. Name of waterbody: 1b. Municipality:

1c. Is the waterbody privately owned? Note: The waterbody is considered a private pond when it is a person owning a natural pond of not more than 20 acres or an artificial pond entirely upon his or her premises.

Yes

No

2a. Provide a description of the control activity. Check the boxes below to certify that the control activity will not exceed 1,500 square feet and will be at least 50 feet from a previously authorized control activity. Attach a map to this application proposing the footprint of the control area. For example, a registered lake association may identify the waterbody as the control area and an individual shoreline property owner may identify their control area as being immediately adjacent to their point of access to the waterbody, such as at their dock or swimming area. Proposed control areas may be altered based on technical review. Once after receiving authorization, a proposed control activity outside of the authorized control area would require an amendment to the authorization.

Note: The control activity is not eligible for ANCGP coverage if the control activity exceeds 1,500 square feet and is within 50 feet from a previously authorized control activity.

2b. The control activity does not exceed a cumulative surface area of 1,500 square feet:

2c. The control activity is at least 50 feet from a previously authorized control activity:

3. Are there wetlands associated with or adjacent to the control area?

(Contact the Wetlands Program (802) 828-1535 or https://dec.vermont.gov/watershed/wetlands/contact)

Yes

No

4. Are there rare, threatened, or endangered species associated with the waterbody?

(Contact the Vermont Fish & Wildlife Natural Heritage Inventory (802) 828-1000)

Yes

No

5a. Within the proposed control area, will the project involve the use of benthic barriers, diver assisted suction harvesting, or a combination of the two?

Benthic barriers

Diver assisted suction harvesting

5b. If proposing to use benthic barriers, identify the type of benthic barrier material and attach a copy of the manufacturer’s product description to the application:

D. Applicant Certification

As APPLICANT, I hereby certify that the statements presented on this application are true and accurate; guarantee to hold the State of Vermont harmless from all suits, claims, or causes of action that arise from the permitted activity; and recognize that by signing this application, I agree to complete all aspects of the project as authorized. Submission of this NOI constitutes notice that I have read, understand, and agree to comply with all applicable terms and conditions of the general permit. I understand that failure to comply with the foregoing may result in violation of the 10 VSA Chapter 50, § 1455, and the Vermont Agency of Natural Resources may bring an enforcement action for violations of the Act pursuant to 10 V.S.A. chapter 201.

Applicant Signature: __________________________________________________ Date: _____________________

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E. Application Preparer Certification (Check the box to the right if not applicable )

F. Administratively Complete Certification (use the checklist below to be sure you have completed all requiredsections of this application form)

All sections of this application are complete (or otherwise indicate "not applicable").

A map is included that outlines the proposed control area and identifies the surface area of the project.

If the applicant is a lake association, application includes a copy of its approved registration form, or if not previously registered, a new registration form.If proposing to use benthic barriers, application includes a copy of the manufacturer’s product

description.

Fee included as a check payable to State of Vermont.

Total Fee due: _________________________

Submit this form and review fee to: Vermont Department of Environmental Conservation Watershed Management Division – Lake & Shoreland Permitting 1 National Life Drive, Davis 3 Montpelier, VT 05620-3522

Refund Policy: Review Fees are non-refundable unless an application is withdrawn prior to administrative review.

For Department Use Only VERMONT DEPARTMENT OF ENVIRONMENTAL CONSERVATION AUTHORIZATION

A determination has been made that the proposed aquatic nuisance control activity in waters of the State qualifies for coverage under the ANCGP. Subject to the terms and conditions of the ANCGP and the NOI, the Applicant is hereby authorized to conduct an aquatic nuisance control activity in waters of the State.

Emily Boedecker Commissioner Department of Environmental Conservation

By: _____________________________________________ Lakes and Ponds Management and Protection Program

As APPLICATION PREPARER, I hereby certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

Applicant Preparer Signature: ___________________________________________ Date: ___________________

Project is proposed in private waters: $25.00

Project is proposed in all other waters: $50.00

G. Review Fee (check one)